Cycle 1
Health 2025-03-27 · Fire 2025-03-27
1 health deficiencies
Top issue: Infection Control (1 deficiency)
3 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Kalona, IA
Pleasantview Home
5-star overall rating with 5-star inspections with 1 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
811 Third Street, Kalona, IA
(319) 656-2421
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
70
Certified beds
Average residents
59
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2002-09-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.83
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
0.44
Licensed practical nurse staffing · state 0.57 · national 0.87
Aide hours / resident day
3.10
Nurse aide staffing · state 2.53 · national 2.35
Total nurse hours
4.38
All reported nurse hours · state 3.83 · national 3.89
Licensed hours
1.28
RN + LPN hours · state 1.30 · national 1.54
Weekend hours
3.90
Weekend nurse staffing · state 3.35 · national 3.43
Weekend RN hours
0.40
Weekend registered nurse coverage · state 0.50 · national 0.47
Physical therapist
0.03
Reported PT staffing · state 0.04 · national 0.07
Adjusted RN hours
0.95
CMS adjusted RN staffing hours
Adjusted total hours
5.01
CMS adjusted total nurse staffing hours
Case-mix index
1.19
Higher values indicate more complex resident acuity
RN turnover
50%
Annual RN turnover · state 44% · national 45%
Total nurse turnover
48%
Annual nurse turnover · state 44% · national 46%
SNF VBP
Value-based purchasing
Program rank
424
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
70.23
Composite VBP score used to determine payment impact.
Payment multiplier
1.0225
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
4.05
Baseline 26.56% · Performance 47.14% · Measure score 4.05 · Achievement 4.05 · Improvement 0
Adjusted total nurse staffing
10
Baseline 4.66 hours · Performance 6.05 hours · Measure score 10 · Achievement 10 · Improvement 9
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.33% |
10.72%
0.4 pts better
|
No Different than the National Rate · Eligible stays 34 · Observed rate 5.88% · Lower 95% interval 6.2% |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 24 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | 0.59 |
1.02
0.4 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 30 · Denominator 30 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 30 |
| Discharge self-care score | 30.43% |
53.69%
23.3 pts worse
|
Numerator 7 · Denominator 23 |
| Discharge mobility score | 34.78% |
50.94%
16.2 pts worse
|
Numerator 8 · Denominator 23 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 30 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 15 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 6.51% |
8.2%
1.7 pts worse
|
Numerator 11 · Denominator 169 |
| Staff flu vaccination coverage | 12.97% |
42%
29 pts worse
|
Numerator 24 · Denominator 185 |
| Discharge function score | 43.48% |
56.45%
13 pts worse
|
Numerator 10 · Denominator 23 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.4 |
1.5
0.1 pts better
|
1.9
0.5 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.4 · Observed 1.0 · Expected 1.3 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.3 |
2.1
0.8 pts better
|
1.8
0.5 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.3 · Observed 1.0 · Expected 1.3 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
94.0%
6 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.3% |
95.2%
3.1 pts better
|
95.5%
2.8 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.3% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.4% |
3.7%
1.7 pts worse
|
3.3%
2.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.4% · Q2 3.7% · Q3 7.0% · Q4 5.6% · 4Q avg 5.4% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 2.5% |
4.0%
1.5 pts better
|
11.4%
8.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.0% · Q2 0.0% · Q3 5.9% · Q4 2.1% · 4Q avg 2.5% |
| Percentage of long-stay residents who lose too much weight | 4.9% |
4.9%
About the same
|
5.4%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.0% · Q2 6.1% · Q3 4.3% · Q4 2.3% · 4Q avg 4.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 13.9% |
20.6%
6.7 pts better
|
19.6%
5.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.0% · Q2 14.3% · Q3 14.9% · Q4 13.3% · 4Q avg 13.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 24.1% |
19.8%
4.3 pts worse
|
16.7%
7.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.1% · Q2 24.4% · Q3 29.3% · Q4 21.1% · 4Q avg 24.1% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.2%
0.2 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 15.6% |
18.5%
2.9 pts better
|
16.3%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 27.4% · Q2 13.0% · Q3 16.4% · Q4 4.9% · 4Q avg 15.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 14.4% |
18.3%
3.9 pts better
|
14.9%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 18.6% · Q2 12.5% · Q3 10.9% · Q4 15.9% · 4Q avg 14.4% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.5% |
1.7%
0.2 pts better
|
1.0%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.2% · Q3 3.8% · Q4 0.0% · 4Q avg 1.5% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.3% |
2.5%
0.2 pts better
|
1.7%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.9% · Q3 3.6% · Q4 3.8% · 4Q avg 2.3% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 21.5% |
26.0%
4.5 pts better
|
19.8%
1.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.0% · Q2 27.7% · Q3 18.3% · Q4 20.1% · 4Q avg 21.5% |
| Percentage of long-stay residents with pressure ulcers | 6.2% |
4.3%
1.9 pts worse
|
5.1%
1.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.8% · Q2 7.1% · Q3 7.7% · Q4 1.9% · 4Q avg 6.2% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 86.7% |
84.3%
2.4 pts better
|
81.7%
5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q2 80.0% · Q3 90.0% · Q4 95.7% · 4Q avg 86.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 19.9% |
13.1%
6.8 pts worse
|
12.0%
7.9 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 19.9% · Observed 19.0% · Expected 10.7% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 4.5% |
1.9%
2.6 pts worse
|
1.6%
2.9 pts worse
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 4.5% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 95.0% |
73.3%
21.7 pts better
|
79.7%
15.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 95.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 22.8% |
21.3%
1.5 pts worse
|
23.9%
1.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 22.8% · Observed 19.0% · Expected 19.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-06-13 · Fire 2024-06-13
0 health deficiencies
No concentrated health issue counts in this cycle.
2 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Cycle 3
Health 2023-03-23 · Fire 2023-03-23
2 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
1 fire-safety deficiencies
Top issue: Miscellaneous (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-03-27
K346 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Corrected 2025-04-04
F · Potential for more than minimal harm
2025-03-27
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2025-04-04
E · Potential for more than minimal harm
2025-03-27
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-04-04
F · Potential for more than minimal harm
2024-06-13
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2024-06-21
F · Potential for more than minimal harm
2024-06-13
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2024-06-28
F · Potential for more than minimal harm
2023-03-23
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-03-27
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-03-27
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-04-11
D · Potential for more than minimal harm
2024-02-22
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-03-19
D · Potential for more than minimal harm
2023-03-23
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-03-24
Penalties and ownership
What sits behind the stars
Ownership
Bender, Vickie
Operational/Managerial Control · Individual
Bontrager, Julie
Corporate Officer · Individual
Danker, Michelle
Operational/Managerial Control · Individual
Drobot, Ann
Operational/Managerial Control · Individual
Eberly, Scott
Operational/Managerial Control · Individual
Gingerich, Midori
Operational/Managerial Control · Individual
Hershberger, James D
Operational/Managerial Control · Individual
Hershberger, Renee
Operational/Managerial Control · Individual
Hershberger, Ronnie
Corporate Director · Individual
Janecek, Jessica
Operational/Managerial Control · Individual
Kauffman, Merlin
Corporate Director · Individual
Lehman, Kent
Operational/Managerial Control · Individual
Logan, Marlan
Corporate Officer · Individual
Miller, Wendell
Corporate Director · Individual
Ramer, Herber
Corporate Director · Individual
Riley, Sean
Operational/Managerial Control · Individual
Schrock, Karen
Operational/Managerial Control · Individual
Sojka, Julie
Corporate Officer · Individual
Swartzendruber, Larry
Operational/Managerial Control · Individual
Troyer, Patricia
Corporate Director · Individual
Usda Department Of Agriculture Rural Development
5% Or Greater Mortgage Interest · Organization
Yoder, Debra J
Corporate Officer · Individual
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